Monday, September 30, 2013

Kudos to The New York Times Magazine for Examining the "Feel-Good War" on Breast Cancer!

In last week's The New York Times Magazine, Peggy Orenstein wrote an article called "Our Feel-Good War on Breast Cancer".  The piece is lengthy but well researched, insightful, and well worth the reading time.

Peggy, a breast cancer survivor herself, hits every key public health issue- cancer screenings, treatment options, "awareness" raising, message framing, funding, and research.  As someone who has been critical of "awareness" raising, I was happy to see the issue discussed front and center.  For me, her interview with Dr. Gayle Sulik (Sociologist and Founder of the Breast Cancer Consortium) was the most striking.  A key quote from Dr. Sulik (I added the bolding):

“You have to look at the agenda for each program involved.  If the goal is eradication of breast cancer, how close are we to that? Not very close at all. If the agenda is awareness, what is it making us aware of? That breast cancer exists? That it’s important? ‘Awareness’ has become narrowed until it just means ‘visibility.’ And that’s where the movement has failed. That’s where it’s lost its momentum to move further.”

Peggy also tackles the issue that is an ongoing challenge in public health and medicine:  screening.  Screenings are tests that look for diseases before you have symptoms.  Ideally, screening will identify diseases early when they are easier to treat and have better outcomes.  For breast cancer, the key screening test is a mammogram (x-ray of the breasts).  However (as Peggy points out), we seldom hear about the research that demonstrates limited effectiveness of mammograms for reducing cancer death.  This is not the research cited in the communication materials from advocacy organizations.  We also tend not to hear about the negative side effects of screening large segments of the population.  There can be false positive tests: which subject the patient to unnecessary medical intervention and emotional distress.  There can also be over-treatment for the detected cancer, even if it turns out to be a non-aggressive tumor.

When I was working in suicide prevention, one of the best articles I read was "Screening as an Approach for Adolescent Suicide Prevention" by Dr. Juan Pena and Dr. Eric Caine.  The authors dedicate a section of the paper to key decisions and tasks to resolve before implementing a screening program.  While the public health issue and screening tests are different, I believe many of their decision points are generalizable to almost any health issue.  The table presenting these decisions and tasks is a great reminder to public health professionals and clinicians that recommending and undertaking a screening program should be strategic and the decision should be re-visited regularly.  For example, the authors highlight:
  • Key Decision:  Population and Setting- Is the screening program consistent with the target population's community or cultural values?
  • Key Decision:  Screening Instrument- What will be the false positives and false negatives rates in the population to be screened?  Are these rates acceptable?
  • Key Decision:  Staffing and Referral Network- Are there effective treatments available for the types of conditions being screened for?
  • Key Decision:  Quality Assurance- How will the screening program be monitored to ensure that protocols are followed?
  • Key Decision:  Legal and Ethical Issues- Has sufficient informed consent been given to parents and youth about risks, benefits, and limits of screening?

Going back to the "Feel-Good War" article:  I like that Peggy did not just point out all the flaws in our current breast cancer screening and treatment systems.  Instead, she invited her interviewees to recommend potential improvements.  Some ideas were noted in two key areas:
  • Message Re-Framing:  Rather than offering blanket assurances that “mammograms save lives,” advocacy groups might try a more realistic campaign tag line. The researcher Gilbert Welch has suggested this message, “Mammography has both benefits and harms — that’s why it’s a personal decision.”
  • Funding Re-Distribution:  Peggy asked scientists and advocates how some of that "awareness" money could be spent differently. She highlights the February recommendations of a Congressional panel (made up of advocates, scientists and government officials) that called for increasing the share of resources spent studying environmental links to breast cancer. They defined the term liberally to include behaviors like alcohol consumption, exposure to chemicals, radiation and socioeconomic disparities. 

Tell Me What You Think:
  • What do you think about the "pink culture" or awareness raising around breast cancer?  Will it effectively lead us to our goal of prevention?
  • In addition to message re-framing and funding re-distribution, what else would you recommend to help improve the approach to breast cancer prevention, screening, and treatment?

Sunday, September 29, 2013

"Call the Midwife": Public Health in the 1950s and Today

Are other people in love with "Call the Midwife" like I am?  I started watching last year during a break between Downton Abbey seasons.  The show follows the lives and work of nurse/midwives working in the Poplar community of east London in the 1950s.  The community has a high poverty rate and limited resources.  The series is based on the memoirs of Jennifer Worth, who like the main character Jenny Lee, became a midwife at the age of 22.

Season 2 of Call the Midwife (airing in the U.S. March 31-May 19, 2013) has been packed with public health issues.  I have been struck by how many of the highlighted issues still challenge us today:

  • Season 2, Episode 1: Jenny Lee begins to care for a young mother named Molly, pregnant with her second baby.  In the course of their visits, Jenny realizes that Molly is a victim of domestic violence.  In one especially poignant scene, Jenny soothes and encourages Molly via a conversation held through the family's mail slot. Molly has been ordered by her husband not to let Jenny in the house.
Domestic violence (or intimate partner violence- abuse by a current/former partner or spouse) is still a problem today.  The Centers for Disease Control & Prevention (CDC) estimates that it affects millions of Americans.  This violence has long-term economic and health consequences for individuals, families, and communities.  The CDC offers many resources focused on public health's role in the prevention of intimate partner violence.
  • Season 2, Episode 5: Jenny Lee provides prenatal care to Nora, a mother of 8, living in poverty.  The family of 10 crowds into a 2 room flat.  When Nora finds out that she is pregnant again, she is desperate to end the pregnancy.  With the family's financial situation, she feels that it is impossible for her family to take care of another child.  Jenny confronts Nora after seeing evidence of self harm.  Jenny reminds her that there is only one way to terminate a pregnancy (abortion), but it is illegal.  Nora risks her life seeking the services of a local woman who performs abortions.
Abortion remains a hotly debated public health issue in the U.S. both at the state and federal level.  This episode of "Call the Midwife" is a grim reminder of what can happen when women do not have access to safe, legal abortions.
  • Season 2, Episode 6:  After diagnosing several late-stage Tuberculosis (TB) infections in Poplar, the community physician (Dr. Turner) advocates for a screening program in the form of an x-ray van.  Dr. Turner and Sister Bernadette (a nun/midwife) make a wonderful public health argument for the resources they need.  They cite the risk factors, specifically poverty in their community, noting that families may have up to 12 people in one apartment.  The close living quarters increase the chance of spreading this infectious disease.  In fact, we meet one family in the episode that lost 6 children to TB.  As a public health professional, it was fascinating to see the promotional materials that the clinicians created to recruit people for the screening.  They papered local bars with flyers and set a large sign outside the van reading, "Stop. 2 minutes may save your life. Get a chest x-ray".
Infectious diseases and their screening, treatment, and vaccination remain key public health issues in the U.S. and around the world.  Many infectious diseases like measles or chickenpox can be prevented by vaccines.  Over the past 15 years, there has been much discussion between the public and public health communities about the safety of vaccines for children.  In January 2013, the Institute of Medicine released a report reaffirming that the current childhood vaccine schedule is safe.  In fact, they report that "vaccines are one of the safest public health options available".

Tell Me What You Think:
  • What have been your favorite episodes of "Call the Midwife"?
  • What other public health issues are portrayed in the 1950s that still challenge us today?

Social Media: Providing Connections, Voices, Adventures to Many with Chronic Illness

I am in awe of social media.  

I am in awe of it in my professional life.  I have connected with colleagues all over the world who share my passion for public health, health communication, blogging, pop culture- you name it.

I am also in awe of it in my personal life.  As someone who lives with a chronic illness, I have connected with others who suffer from similar symptoms, offer support, advocate for patient rights, and recommend creative solutions to balancing work and life.

In the past month, I have been struck by several examples of how social media is transforming the lives of people with chronic illness.  Without the networks available within social media, many of these people may have been very isolated due to their conditions.

On March 11, 2013 NBC Nightly News with Brian Williams ran a story about Virtual Photo Walks.  The project's tagline is "Walk the walk for those who can't".  Using the social media platform Google+, Virtual Photo Walks enables people to become "interactive citizens" again.  They connect with smart phone enabled photographers to "travel" and see places and people that they used to see...or always wished that they could.  The news story profiled a woman with Lupus who could not travel due to her serious health condition.  She always wanted to go to Italy and with Google+ she did.  We watched World War II veterans no longer able to travel, "visit" the USS Arizona Memorial through the collaboration of photographers and Google +.  It was incredible to watch.    

On April 5, 2013 CNN Tech ran a story called "On Twitter, Roger Ebert Found a New Voice".  The story describes how Roger became an avid twitter user in 2010, years after cancer had silenced his voice.  He wrote, 

"Twitter for me performs the function of a running conversation. For someone who cannot speak, it allows a way to unload my zingers and one-liners".

As someone growing up in the 80's, I regularly watched "Siskel and Ebert and the Movies".  Keeping up with Roger through twitter and his blog "Roger Ebert's Journal" in recent years has been a seamless transition.  I felt like the show never ended.  I kept up with his running commentary and of course- his movie reviews.

Sustaining your presence in the world is important with a chronic illness.  I felt that point strongly when reading his final blog post, "A Leave of Presence".  

"What in the world is a leave of presence?  It means I am not going away".  

Please Share:
  • What creative ways do you see social media being used to support those with chronic (or acute) illnesses?
  • Why do you think these communication channels are so effective in "sustaining your presence"?

Saturday, September 28, 2013

Writing Public Health Blogs: Do We Get Back What We Put In?

Last week I attended a great webinar hosted by AcademyHealth called: “Traditional and New Methods for Disseminating What Works”.  One of the speakers was Dr. David Kindig and he touched on the evaluation component of writing a public health blog- do we get back what we put in?  As the tweet below indicates, this is an important question for all of our blogs.

My exploration of this question nicely coincides with the theme for this week’s National Public Health Week- “Return on Investment”.  I was initially going to write just my own thoughts, but then decided it would be a much richer piece if I could incorporate input from other public health bloggers.  The following colleagues were kind enough to send me their thoughts:

Jim Garrow: The Face of the Matter, Public Health Memes
Elana Premack Sandler: Promoting Hope, Preventing Suicide for Psychology Today
Jonathan Purtle: The Public's Health for the Philadelphia Inquirer
Michael Siegel: The Rest of the Story: Tobacco News Analysis and Commentary
Thomy Tonia: International Journal of Public Health-Blog 

1. How much time do you dedicate to your blog per day/week/month?

Jim: I wish I could post more blogs per week; right now I'm averaging about a post a week (sometimes it'll be 3-4 posts in a week, sometimes no posts for a few weeks in a row). Each post takes about an hour between research, linking and writing. And I've got to be constantly on the lookout for new and time-relevant material.

Elana: When I was writing weekly, I spent 3-5 hours a week researching, writing, editing, and posting (using the content management software, sometimes the hardest part!). I have a background in journalism, so I'm able to write and self-edit relatively quickly. Now that I'm posting only once a month, I probably spend 5-7 hours a month between culling through stories of interest, thinking about the relevance of various topics, writing, editing, and posting. It's actually more challenging to post only once a month, as I get out of practice and have more material to comb through to see what rises to the top.

Jonathan: On average, a 500-750 word post takes me 4-5 hours. I currently post twice a month. I used to post weekly, but the time burden was too much. 

Michael: Approximately one hour per day, mostly devoted to writing my daily posts.

Thomy: I blog as part of my job as an Editorial Assistant/ Social Media Editor for the International Journal of Public Health. When I was focused only on the blog, I dedicated about 4 hours per week (divided between blogging and visiting other blogs/public health sites- to get ideas, keep informed and interact). Since I now also manage the twitter and Facebook accounts, I have reduced my blog time to 2-3 hours per week. 

Leah: I spend about 5 hours on each blog post- between finding the story, writing, and marketing the posts on social media. Since I try to address topics that are hot in the news that week or that day (like Jim says above), I'm constantly on the lookout for relevant stories.  Throughout the week I save all my possible stories/links/ideas on a spreadsheet and pick the best one.  While my posting frequency has varied over the past three years of writing Pop Health, my goal is to post at least once per week.

2. Who is the audience for your blog?

Jim: The blogs that I write are written for professionals in the fields of public health and emergency management. My thought is that I can affect more change by finding and teaching best practices to the people on the ground actually working with the public.

Elana: My blog is read by mental health and public health professionals as well as laypeople interested in psychology, mental health, pop culture, and suicide prevention. Since I blog on a site that does a lot of promotion for itself, I have a relatively wide readership. Each post can generate 500-2000 hits; I haven't done any real numbers-running, but 100-300 hits on the day the post is published is probably average, and then each post accrues hits over time.

Jonathan: The general public in Philadelphia and surrounding areas. Given the size of the health care sector in the region, I like to think health professionals read it as well. I also dream that policy makers read it—although I’m not sure if either health professionals or policy makers read

Michael: Incredibly diverse audience of anti-smoking advocates, groups, and researchers, smokers’ rights advocates, government agencies, tobacco companies, newspaper reporters, stock market analysts, consumers, trade groups, and policy makers.

Thomy: Originally, our intended audience was mainly public health students, as we are affiliated with the Swiss School of Public Health. However, especially through social media, our audience seems to be not only public health students and professionals but also people who just have an interest in public health. Nevertheless, it is not easy to know exactly who our audience is, as we do not get a lot of comments and it is difficult to know who actually reads the blog. We try to engage people to write guest posts for us. This generally works quite well.

Leah: I write for a broad public audience with an interest in public health, pop culture, or both. Therefore, I use it as a platform to breakdown and explain public health/communication concepts (e.g., "teachable moments"; "cue to action"). From the analytics, emails, and comments that I receive, I know that I have a large following among public health professionals, students, and teachers.  I have heard from more than one faculty member to say that they use my blog with their students to demonstrate the connection between public health and their everyday lives (e.g., movies, magazines, advertising).

3. What is the ideal “return/s on investment” for your blogging efforts? 

Jim: I've been writing blogs relevant to public health and emergencies for more than six years. I've found it to be one of the best investments I've made in my career, even with the huge investment in time and effort required for success.  I've found that the best return I've realized is my network of contacts and friends across the country and around the world; none of whom I would've met without being available and "out there" online.

Elana: For me, the ideal return on investment is reader engagement. I really get a lot out of seeing reader comments (the good and the not-so-good) and corresponding with readers via the comments section, or with friends and more personal connections on Facebook when I promote my posts there.

Jonathan: The ideal return is three-fold: (1) A public which understands that health is about more than just individual choices. A public which begins to see the reverberating impacts of social/economic policies, beyond the health care sector, on people’s health. A public which is knowledgeable about trauma theory and research on trauma/stress. (2) Networking. (3) Increased readership. While this is the most measurable, I’m not convinced it means all that much. Who’s reading? How are they reading? How is the information changing their perceptions? Is it at all? We have no idea.

Michael: The ideal “return on investment” is the blog having an actual impact on public policy.

Thomy: Increasing readership and dissemination of ideas is always a good return. We would ideally like to have more engagement in the form of interaction (e.g., comments). Networking is also quite satisfying and really helps broaden our blogging horizons. As a public health journal, we are also interested in disseminating our research articles.  I personally would like to see more and more public health students, researchers and professionals having blogs and engaging in social media to learn new things, disseminate their knowledge, “meet” interesting people and also –why not- for the fun of it!

Leah: Pop Health began as a hobby that just happened to incorporate my field of public health.  Now it has become a key part of my professional portfolio.  Therefore, the key returns are now different than three years ago.  Now, I'm looking for increased readership and referrals to my site.  I'm looking for increased dialogue with readers and colleagues.  I'm also looking for new and exciting professional opportunities (e.g., guest blogging, writing, and teaching) that can emerge by branding my expertise in this niche of public health.

4. Do you measure these “returns”?  If so- how?

Jim: I've seen a tremendous benefit professionally. As a direct result of my online identity and interactions, I've been invited to more than a dozen international, national and regional conferences to speak on those topics I blog about.  But even beyond those personal returns, I've seen a tremendous benefit professionally. Not only am I able to call on friends I've made around the globe to help with ideas for work, but I've grown as a result of being forced to flesh out my ideas. When I write about something, I want it to be well thought-out and considered. By writing these ideas out, I am forced to consider not only my idea, but how it affects other, larger problems...Without writing it out, I would just have a nugget of an idea, no more than that.

Elana: I measure this ROI very unscientifically. I notice which topics generate more interest (both in terms of hits, which are tracked by Psychology Today, and comments) either on the Psychology Today site or on Facebook. I've wanted to get more sophisticated with Google Analytics, but can't do that as I don't actually manage the website that hosts my blog. I've also enjoyed meeting people at professional conferences who recognized my name because of my blog. That really blew me away - it meant that I was really reaching people (not just my Mom!).

Jonathan: tracks usage statistics and sends them to us on a weekly basis. Posts on animals, kids, and pop culture typically do the best.

Michael: Yes, but not formally. I assess the actions of public health agencies and organizations to determine whether the blog seems to be changing their thinking about these issues. I also assess the state of public opinion in the field regarding these issues.

Thomy: We keep track of visitors, time spent on blog (etc.) via Google Analytics and StatCounter. We also monitor the most popular posts and try to have some ongoing themes corresponding to these popular posts.  Regarding the “return on investment” to the Journal, we are trying to monitor whether articles that have been featured in the blog are downloaded more often from our website.

Leah: I have used Google Analytics and Blogger Statistics for measurements like page views, referring sites, and key words used to find Pop Health. I also take note of the posts that stimulate more engagement with readers- I would note that more dialogue seems to take place directly on social media where I market the posts (i.e., Facebook & Twitter) vs. the comment section on the blog itself.  As a result of the blog, I have also been invited to guest write on other sites like The Public's Health- so tracking those opportunities helps me to measure return on investment as well.

Evaluation and Return on Investment are key concepts in public health

With public health professionals constantly being asked to do more with less, it is imperative that we show how our investments are paying off. It is important to think of "investments" broadly- they are not just money...they are our time too.  As you can see from the responses to question #1, creating and maintaining a blog is a huge commitment.  And although we write for a variety of audiences with different goals (ranging from promoting research to trying to impact policy), we share the challenge of trying to evaluate those goals.

Therefore, we need to lead ongoing dialogue about the goals and evaluation of public health blogs. CDC's National Prevention Information Network (NPIN) is continuing its "In the Know: Social Media for Public Health" webcasts this spring and the June 4, 2013 event will focus on Measurement & Evaluation.  I look forward to continuing this discussion there and elsewhere.

Thank you again to Jim, Elana, Jonathan, Michael, and Thomy for your contributions!  I appreciate you making the time and sharing your experiences.

I would like to invite other public health bloggers to weigh in on these questions:  

  • How much time do you dedicate to your blog per day/week/month?
  • Who is the audience for your blog?
  • What is the ideal “return/s on investment” for your blogging efforts? 
  • Do you measure these “returns”?  If so- how?

Friday, September 27, 2013

"Girls" Tackles OCD: What I Hope IS NOT Happening In Our Emergency Departments

This afternoon I had the pleasure of having some downtime- so I used it to catch up on the three recent "Girls" episodes sitting on my DVR.  Having avoided spoilers, I was surprised and saddened to see Hannah (Lena Dunham) being consumed by Obsessive Compulsive Disorder (OCD).  We learn that she had a serious bout with the condition once before- in high school.  It was so serious that she sought professional help and medication at that time.  Flash forward to her post-college life and we see her plagued again...perhaps triggered by the stress of a recent break-up and a looming book deadline.

While there are several disturbing issues in the most recent episode "On All Fours" (you can see the comments in Alan Sepinwall's review for those details), I want to focus specifically on Hannah's trip to the local emergency department (ED).

I was very upset watching this scene and I'll tell you why:

We know that emergency room providers are key gatekeepers for those who are suicidal and/or suffering from mental illness.  Research tells us that 1 in 10 suicides are by people seen in an emergency department within 2 months of dying.  Acknowledging the importance of this gatekeeper role, leadership organizations in suicide prevention have created a variety of toolkits and resources to educate and train emergency department personnel to identify patient warning signs and assess their risk.

In "On All Fours", Hannah visits the ED after obsessively sticking a Q-tip in her ear, getting it stuck, and experiencing pain.  After lying to her parents by saying she has "12-15 good friends" to accompany her to the ED, she goes alone.  The scene opens with the doctor telling her, "Well, you must be feeling pretty silly."

As the doctor examines her injured ear, Hannah says:

"I've just been having a little trouble with my mental state."
"I have a lot of anxiety and I didn't think stress was affecting me but it actually is."
"I'm not saying this was an accident, but I was just trying to clean myself out."

At no point does the doctor respond to any of these statements.  He is all business, telling her to follow-up with a specialist if she is still experiencing pain in a few days.  As Hannah lays down so he can put antibiotic drops in her ear, she pleads with him to look at her other ear.  He snaps at her "there is nothing wrong with the other one."  Hannah cries on the bed because it (the drops? her situation?) hurts so bad.

He discharges her and she walks home alone.  In just a t-shirt and no pants.

Now I'm not saying that Hannah was acutely suicidal or verbalized such a threat in the ED.  However, I am saying that she made several clear statements about her mental health that should have been treated with concern and respect by a competent medical provider.  Her demeanor and her appearance deserved a kind ear, a social worker's visit, someone to ask if she was all right.

These recent episodes have been applauded for their accurate portrayal of OCD.  I hope that a future episode will show a portrayal of a caring and skilled provider using the public health prevention and education tools that are available to assist someone in desperate need of help.

For any readers that may need help:

  • The National Suicide Prevention Lifeline:  1800-273-TALK
  • Substance Abuse & Mental Health Services Administration: (SAMHSA) Mental Health Treatment Finder

Seth MacFarlane: An Oscar Host who is Harmful to Comedy and the Public’s Health

This week’s post for Pop Health was co-written by Beth Grampetro, MPH, CHES. Beth has been working in college health promotion for 7 years and her interests include feminism online and in popular culture. You can follow her on twitter @bethg24. 

The role of society is important in public health.  Health is not just influenced by individual decisions and behaviors.  It is also influenced by our interactions with the world around us- our communities, our families, our workplaces, our schools, entertainment, celebrities, and the media.  These interactions can have a very strong influence (good or bad) on the public’s health.

With that in mind, we were horrified to witness host Seth MacFarlane’s monologue and ongoing commentary during Sunday night’s Oscars.  According to Nielsen ratings, approximately 40.3 million viewers tuned in to the Oscar telecast.  This broad audience watched MacFarlane, a widely known celebrity, make jokes about domestic violence, female actresses’ bodies, and various forms of discrimination.

In the opening number, MacFarlane sang a song entitled “We Saw Your Boobs”, about the scenes in various movies where actresses in the audience had appeared topless. While it has been reported that the actresses were in on the joke, it is nonetheless disturbing that this number passed muster- especially given that several of the scenes he referenced were from movies where the actresses he named portrayed rape victims.

Other jokes included a reference to Jennifer Aniston’s past as a stripper, a congratulatory statement about how great all the actresses who “gave themselves the flu” to lose weight looked in their dresses, and a comment about how Latino actors (in this case Javier Bardem, Salma Hayek, and Penelope Cruz) have difficult-to-understand accents “but we don’t care because they’re so attractive.”

MacFarlane also tried some jokes that had men as their targets but still managed to get mud on a few women in the process. He joked that Rex Reed was going to review Adele’s performance (a reference to Reed’s recent movie review in which he called Melissa McCarthy a “hippo”) and made a joke about 9-year-old nominee Quvenzhan√© Wallis dating George Clooney. Some defenders of MacFarlane’s performance argued that these jokes were meant to be about the men in question, but ignored the fact that they were made at the expense of women and girls.

The Oscars are billed as “Hollywood’s Biggest Night”, and it’s incredibly disappointing to see what is the biggest event for the entertainment industry turned into the worst office party in history, complete with a leering coworker who’s creating a hostile environment.  If MacFarlane succeeded at anything, it was reminding women that they’re expected to always be thin, be pretty, and be willing to shut up and take it, lest they spoil the whole evening.

There is evidence to show that (unfortunately) these types of jokes and messages that devalue women are believed and internalized within our communities.  For example, a 2009 study by the Boston Public Health Commission found that over half of teens surveyed blamed the singer Rihanna after she was beaten by her boyfriend Chris Brown.  In addition, research shows that a mere 3-5 minutes of listening to, or engaging in, fat talk can lead some women to feel bad about their appearance and experience heightened levels of body dissatisfaction.

Research also tells us that these internalized messages and social norms are correlated with serious public health outcomes.  For example, the CDC outlines the risk factors for sexual violence perpetration.  Under society level factors we find (among others):

Societal norms that support sexual violence
Societal norms that support male superiority and sexual entitlement
Societal norms that maintain women's inferiority and sexual submissiveness
Weak laws and policies related to gender equity

So the issue is much bigger than if Seth MacFarlane was funny or made a good Oscar host.  The issue is about the quality of the role models we choose to represent our communities and the messages they send.  These messages can have a broad and long lasting influence on public health.  We hope the Academy will choose wisely next year.

president Promotes ObamaCare Amid Republicans Delaying Efforts

Republican lawmakers are trying hard to block the implementation of the Affordable Care Act popularly known as ObamaCare, which aims to provide affordable coverage for millions of Americans without health insurance. The law also aims to provide more comprehensive coverage and lower costs eventually.
House Republicans have a new strategy to block Obama Care—a compromise to raise the debt ceiling, but they are pushing for a vote to delay the health care law this weekend. Last week, the Republicans forwarded a bill to the Senate seeking to defund Obama Care.
On Thursday, House Speaker John Boehner maintained the position of his fellow Republicans. He said, “The American People don’t want the President’s health care bill.”

President Obama promoting ObamaCare

On the other hand, President Barack Obama is aggressively promoting ObamaCare prior to the implementation of a major provision of the bill on Tuesday, October 1, wherein government-regulated insurance exchanges are set to open.
In his speech at Maryland Community College, President Obama condemned “misinformation” surrounding the law, but he pointed out that Republicans failed in every step they take to stop it. “The closer we got to this date, the more irresponsible folks opposed to this law have become,” according to the President.

What you need to know about Obama Care

Under ObamaCare, most Americans should have health insurance by March 31, 2014. Government regulated insurance “exchanges” will be open for people who do not have health insurance from their employers. Through the “exchanges” people can purchase health insurance from competing insurance companies.
The exchanges will categorize the plans by tiers such as platinum, gold, silver, and bronze. The average cost for a silver plan is around $328 per month. The government will provide a subsidy for those whose incomes are 400% below the poverty level ($94,200 for a family of four) and ($45,960 for an individual).
Insurers cannot penalize people with underlying health conditions. They might be able to save money under the Obama Care if they are currently paying more because of their medical condition. The choice of doctors and hospitals maybe limited compared with their current insurance plans.
Americans who will not be able to buy insurance by March 31, 2014 could face a penalty of more than $95 per adult or 1% of household income in their 2014 tax bill. The penalty will climb to as much as $695 or 2.5% of income by 2016. People paying more than 8% of their income for health insurance and poor adults living in states not expanding Medicaid are exempted.
The health care law does not affect Medicare. Enrollment at government-regulated exchanges starts on October 1, and coverage starts by January 1, 2014.

The compromise: raising debt ceiling, delaying ObamaCare

This week, the House Republicans will propose a bill that would raise the federal government’s debt ceiling, but it contains a provision that would delay implementation of ObamaCare for one year. The bill will also include a provision for future tax reform, and the approval of the Keystone pipeline. The Democrats strongly oppose any budget bill that would defund the health care law.

Reforming Health Reform

It may say something about expectations for the Affordable Care Act that the simplistic “just repeal Obamacare” cries of Congressional Republicans are starting to be supplemented by proposals for its replacement.
The most detailed so far is from the conservative American Enterprise Institute, which has published an unexpectedly non-doctrinaire study authored by Harvard professor Michael Chernew and seven other respected academics.
It’s far from perfect, but it’s worth reading.
Structural details of the AEI proposal, modestly titled “Best of Both Worlds,” aren’t always clear (page 1 lists four “principles,” page 5 lists five “priorities”, and page 16 lists three “major planks”), but it does attempt a bipartisan approach, combining ideas from left and right.
Some of these ideas have been contained in other proposals, such as those of Wyden and Bennett and Fuchs and Emanuel (which may damn the AEI proposal in right-wing eyes), and most recently in a THCB piece by Martin Gayno. They include the elimination of the employer coverage tax preference, the provision of “premium support” subsidies for most individuals, and the establishment of a national insurance exchange. Together, they are designed to encourage individual choice and responsibility and to maximize competition between insurers, while removing some of the inequities of the present system (and of the ACA).
The AEI proposal assumes that eliminating the employer coverage tax preference will result in most individuals obtaining coverage through a national exchange, with national regulation of insurance plans. Current Medicaid eligibles will be included, with the replacement of acute care Medicaid funding by subsidies for conventional coverage. All individuals will be able to choose between fully-subsidized “basic plans” and more generous partially-subsidized options, typically with substantial deductibles tied to income and health status. Insurers will be encouraged to offer multi-year coverage and, unlike in the ACA, medical underwriting will be allowed. The only government financing will be for premium subsidies, to be funded by the additional income and payroll tax revenues resulting from elimination of the employer tax preference and by redirecting federal and state Medicaid payments.

A Dozen Hospitals Are Laying Off Staff and Blaming Obamacare. Don’t Believe Them.

Hospitals tend to be among the largest employers in their communities — which means that any individual decision to lay off staff can have an outsized local impact. And taken together, a dozen recent announcements seem to paint an especially dire picture for hospitals (and their communities) around the nation.
For example, NorthShore in Illinois says it will lay off 1% of its workforce. The staffing cuts “ensure NorthShore remains well positioned to deal with the unprecedented changes brought on by the Affordable Care Act,” according to a memo from the health system’s chief human resources executive.
And California’s John Muir Health is offering staff voluntary buyouts ahead of ACA implementation. “We’re being paid less, and we either stick our head in the sand or make changes for the future so patients can continue to access us for their care,” according to John Muir spokesperson Ben Drew.
When Obamacare was being debated in Congress, its opponents tried to tar it with a deadly label: “the job-killing health law.” So is the ACA finally living down to its sobriquet?
Not exactly. While the recent news makes for provocative headlines, the devil’s in the details — and the financial reports.
A Closer Look at Industry Pressures
It’s clear that something is shifting in the hospital market. After years of employment growth, hospitals’ hiring patterns have largely leveled off. Collectively, organizations shed 9,000 jobs in May — the worst single month for the hospital sector in a decade.
Some of those decisions reflect industry-wide belt-tightening, as Medicare moves to rein in health spending by moving away from fee-for-service reimbursement and penalizing hospitals that perform poorly on certain quality measures.
And uncertainty around ACA implementation is trickling down to hospital staffing decisions, economists told  me. Many organizations still aren’t sure how the pending wave of newly insured patients will affect their profit margins, given that many of these individuals may be sicker and will be covered by Medicaid, which reimburses hospitals at lower rates than Medicare and private payers.

Thursday, September 26, 2013

Using Twitter to Track Disease: Weighing the Advantages and Challenges

A few weeks ago I participated in a fantastic twitter chat on the use of social media for public health.  During the event, our moderators posed the following question: "Are there any other diseases (besides the flu) that we could track on social media?"

The question generated a very lively discussion that I was inspired to revisit on Storify this morning after reading the Washington Post's article, "Twitter becomes a tool for tracking flu epidemics and other public health issues."

The WP article highlights several advantages and challenges of monitoring public health diseases and/or conditions on twitter.  My twitter chat colleagues brought up many other important issues for us to consider, so I'm including these expanded lists:


  • Offers real time data on health or behavior (Government data can often take weeks or months to be released)
  • There is so much available data! 
  • It could capture cases that would not otherwise be formally documented at a physician's office or hospital.
  • It has proved helpful in tracking time sensitive disease outbreaks (e.g., Novovirus).  *Check out this article about how twitter was used to track Norovirus activity during a journalism conference.


  • Accuracy and case definition (i.e., does a twitter user really have the flu or just a bad cold?)
  • Tracking specific words like "sick" or "flu" can bring up a lot of content that is unrelated to the twitter user being ill themselves (e.g., "I'm so sick of this terrible weather").  *Check out how Johns Hopkins researchers are working to address this problem by better screening tweets.
  • We must differentiate between tracking symptoms vs. tracking cases- they are not the same.
  • Our search strategies should include various terms or slang that are used to describe the disease or behavior of interest.
  • Caution: media coverage of certain illnesses can cause a spike in key words on twitter without a rise in actual cases.
  • What are the privacy concerns?
  • Twitter might not thoroughly capture diseases or conditions that carry stigma (e.g., mental illness) because users may be hesitant to discuss them in a public forum.
  • Results could be skewed by populations who are over or under represented on twitter.
  • Do we need to train "trackers" to intervene? E.g., what if they are monitoring dangerous tweets/behaviors like suicidal ideation and attempts?
While the challenges list is quite long, I hope we are not discouraged!  I think twitter is an enormous resource for public health professionals.  We just need to be thoughtful and thorough regarding how to use twitter effectively.

More Resources:

The Washington Post article and related stories shared great links to more information about research in this area:
  • YouTube video on University of Rochester efforts to track influenza on twitter.  It also describes their related app: Germ Tracker (warning: it may have you hopping off your regular morning bus). 
  • Johns Hopkins University article: "You Are What You Tweet: Analyzing Twitter for Public Health".
  • Brigham Young University article: "'Right Time, Right Place' Health Communication on Twitter: Value and Accuracy of Location Information".
  • A great article that highlights what we can learn from Google Flu (since their predictions were off this year)- emphasizes the importance of "re-calibrating" your models or algorithms each year.
What Do You Think?
  • What other advantages and/or challenges should we add to the list?
  • What other resources can you share?

Wednesday, September 25, 2013

Emergency Response to the Boston Marathon Bombings: Looking to Social Media for Information, Resources, and Connections

Boston is my second home.  I lived there for 6 years.  I went to school there.  I made some of the best friends of my life there.  I got married there.  I spent many Marathon Mondays along the race route cheering for friends, colleagues, and absolute strangers.  As many have reported on the news, Marathon Monday is the best day of the year in Boston and you have to experience it to truly understand its excitement and feeling of community.

I am absolutely heartbroken about yesterday's bombing at the Marathon.  In tears, I sat and watched the news alone in my home.  However, I did not feel alone.  As news broke, I quickly connected with Boston friends via text and social media to make sure they were okay.  Many had been watching at various points along the route.  I also connected with public health colleagues to follow the news and to catalog resources and information being deployed to my friends in Boston and also to those of us watching from home.

As with Hurricane Sandy last November, I think it is important to document all the ways that social media is being used to disseminate information and support public health and emergency management.  Here are the key themes that I saw:

Immediate Public Safety Concerns and Instructions

With the #tweetfromthebeat hashtag, Boston Police communicated regularly with twitter followers, instructing marathon spectators to clear the area around the finish line and refrain from congregating in large crowds.


To assist with the investigation, Boston Police and FBI are asking all spectators and eyewitnesses to submit video and photos taken at the finish line.  This message has been widely disseminated via social media.

Reconnecting Runners, Spectators, and Resources

As we have seen with emergency management of natural disasters, social media and technology play a critical role in reconnecting victims with their families and friends.  For example, the following resources were quickly deployed on social media:

  • American Red Cross: Safe and Well
  • Google: Person Finder
  • Google document: Local Boston residents offering shelter to displaced runners/friends/families

Resources for Journalists

Along with tweets from respected news organizations and reporters reminding each other not to speculate early on in the investigation, there were also formal resources circulated regarding how to effectively cover such a story.  For example, the Dart Center for Journalism & Trauma offers comprehensive resources on the reporting of disasters and terrorist attacks.  A resource focusing specifically on the Boston Marathon bombings was tweeted out:

Mental Health & Support Resources

Many public health professionals linked to resources to support those in distress following the bombings and/or those who needed help communicating about the events (e.g., discussing it with children).

HHS Secretary Sebelius tweeted about federal disaster resources:

Philadelphia (like many other cities) tweeted about local disaster resources:

Massachusetts General Hospital and other organizations tweeted out tips for discussing the Boston Marathon bombings with children:

As I discussed in my coverage of Sandy, the power of social media also brings challenges to public health and emergency management.  We have seen some early postings about the lessons learned from this event- which does include a discussion of concerns such as rumors spreading rapidly on social media.  For example, it was first reported that cell coverage in Boston was being turned off so that additional bombs could not be detonated remotely.  We later learned that information was not true.  The cell service was slow or not operational due to the extreme overload of users trying to communicate simultaneously.  There was also a lot of concern about very disturbing images of the crime scene and victims being shared on social media.

So there is much to learn about the use of social media for public health and emergency management through close examination of this event and others.  In any case, it is very clear that social media needs to be a part of every organization's disaster and response plan. 

Tell me what you think:
  • What was your impression of the use of social media by federal/state/local organizations yesterday after the Boston Marathon bombings?  
  • Can you share additional examples of how it was used effectively?  
  • What did you see that concerned you?

Tuesday, September 24, 2013

A Pop Health Book Review of “In the Kingdom of the Sick: A Social History of Chronic Illness in America”

In 2009 I read "Life Disrupted: Getting Real about Chronic Illness in Your Twenties And Thirties".  Since the book inspired me personally and professionally, I was delighted that Twitter enabled me to connect directly with the author Laurie Edwards.  I was even more delighted when she asked to interview me for her new book, "In the Kingdom of the Sick: A Social History of Chronic Illness in America".  Since Pop Health focuses on health communication and the coverage of public health issues in the media, we had plenty of mutual interests to discuss!

"The very nature of chronic illness- debilitating symptoms, physical side effects of medications, the gradual slowing down as diseases progress- is antithetical to the cult of improvement and enhancement that so permeates pop culture." 
("In the Kingdom of the Sick", page 34)

Early in the book, I found this quote incredibly powerful.  It is true.  Our society values and spotlights those that overcome adversity- those that inspire us- those that beat the odds.  Before his fall from grace, we can all remember the worldwide cheering for Oscar Pistorius- making history last summer for being the first double-amputee to compete in the Olympic games.  Edwards highlights those societal values in her book by drawing on the imagery found in many commercials for breast cancer research and fundraising.  Those commercials show an unforgettable image, a "cancer survivor triumphantly crossing the finish line in her local fund-raising event surrounded by earnest supporters."  That triumphant image is a far cry from what Edwards and colleagues term the "Tired Girls" (i.e., female patients suffering with "invisible illnesses" like fibromyalgia, chronic fatigue syndrome, and migraines).  "The Tired Girl stands for so much that society disdains:  weakness, exhaustion, dependence, unreliability, and the inability to get better" (page 103).

The good news is that many of the "Tired Girls" (and Guys) are getting connected and getting empowered.  Edwards dedicates a significant portion of her book to the discussion of "patients in the digital age."  She describes the emergence of "e-patients" (those that are empowered, engaged, equipped, enabled) and how they are using technology to actively participate in the development of their care plans, connect with patients with similar diagnoses, give voice to their experiences, advocate for policy change, and debate controversial topics like vaccinations.

As a public health professional with significant interest in health communication, I was fascinated by a recurring theme that Edwards highlights from these conversations among empowered patients and writers:

"How does language influence the illness experience?"          

The reader is led through an intriguing discussion of the use and implications of terms such as:

  • Illness vs. Disease
  • Illness vs. Chronic Condition
  • Illness vs. Disability
  • Military Metaphors (e.g., "the battle against disease")
  • Chronic Pain Patient vs. Patient with Chronic Pain
  • Healthy Disabled vs. Unhealthy Disabled
  • Patient (does it connote passivity?)

"In the Kingdom of the Sick" is a fascinating read for anyone with a personal and/or professional connection to chronic illness.  It begins by giving you a strong foundation in the history of illness, research, and patient advocacy movements.  It then challenges you to consider the impact of advances in patient rights, science, communication, and technology on the incidence, treatment, and perception of chronic illness.  I highly recommend this book to my Pop Health readers, friends, and colleagues.

If you are interested in connecting with Laurie Edwards:

Monday, September 23, 2013

Baby on Board Badges May Reduce Awkwardness...But Can They Also Increase Safety?

Yesterday many media outlets were thrilled to report that Kate Middleton, Duchess of Cambridge received a "Baby on Board" badge during a visit to the London Underground (the city's subway system).  The badge initiative, first piloted almost a decade ago, was developed after internal research by Transport for London (TfL) showed that pregnant women often felt awkward or uncomfortable asking if they could sit down.  The research also revealed that most travelers believed that mothers-to-be should be offered a seat.  The developers hoped that the badges would give women confidence to ask for a seat and encourage fellow passengers to offer theirs without being asked.

In all the coverage of this initiative, I have (unfortunately) not seen any discussion of evaluation.  The badges are used broadly in London (and other countries like Ireland use them as well).  However, we do not know if they have successfully increased women's confidence to ask for seats or increased a non-provoked seat offer by their fellow travelers.  In addition to these goals, I wonder about how these badges could also be connected to the safety of pregnant women riding public transportation.

This week I had the pleasure of meeting a friend's 11-week old son.  She rode the subway to work all through her pregnancy and we discussed the potential risks that the ride entailed.  While she was comfortable with the ride, her co-workers were often worried about her choice of transportation.  What if she couldn't get a seat?  What if she fell?  What if someone fell into her on the crowded train?  My friend described the experience of having a student's backpack pressed up against her belly late in her pregnancy...which then prompted her to take an alternate mode of transportation to work the next day.

So what if the "Baby on Board" badges could do more than just reduce awkwardness for pregnant women and their fellow passengers?  What if this badge initiative could also reduce the number of pregnant women standing on crowded trains, putting them at risk for falls and other injuries?

First, we would need strong baseline data to determine if a public transportation prenatal injury problem even exists.  Then we would need to evaluate that data during and after the initiation of a badge program in the U.S.  We would also need to evaluate the effectiveness of the badges as a visual cue (e.g., Do passengers recognize the badges?  Do they understand what action they should take upon seeing the badges? i.e.,- giving up their seats).

What do you think?

  • Are you aware of research/studies on public transportation prenatal injury?  If so- please share!
  • For those readers/friends/colleagues that have ridden public transportation while pregnant:  Did you feel at risk for injury?  Did you ever suffer an injury?
  • What do you think about the potential for "Baby on Board" badges to prevent injury?  Are there other strategies that may be more effective?


Sunday, September 22, 2013

Insulin and weight gain

Weight gain is a common side effect for people who take insulin. However, controlling weight is  possible and is also an important part of the overall diabetes management plan.

The connection between insulin and weight gain

Insulin allows glucose to enter the cells so that the level of blood glucose drops. However, if a person’s calorie intake is high and activity level is low, then there

Angelina Jolie's "Medical Choice" Dominates the Internet

I woke up this morning to the quintessential Pop Health story.  Angelina Jolie published an op-ed called "My Medical Choice" in the New York Times.  She talks about undergoing a preventative double mastectomy in February 2013 after genetic testing revealed that she carried the BRCA1 gene.

As I inventoried her column and the online chatter today, I worried that I missed the boat!  Dozens of bloggers and news outlets wrote about her op-ed within hours of its posting...what else could I add to the conversation?

With so many posts for readers to sift through- many of which focus on very specific issues (e.g., the efficacy of preventative mastectomies)- I decided to add to the conversation by cataloging the public health implications being discussed:

Angelina as a "champion" for breast cancer prevention: will her celebrity status help or hurt the cause?:  Most of the articles and comments that I read in response to her op-ed were overwhelmingly positive.  This is exemplified by an open letter on written by Dr. James Salwitz.  He praises Angelina for her bravery and leadership in the battle against breast cancer.  He goes on to state, "Your action will save more lives than all the patients I could help, even if I were to practice oncology for hundreds of years".  On the flip side, a few writers/commenters raised the concern that Angelina's influential status in conjunction with her decision to have surgery could cause women to panic about their own breast cancer risks.  For example, David Kroll writes for Forbes, "For all the bravery of Ms. Jolie and the positive groundswell that her op-ed generates, I also want to be sure that women with breast cancer - women who are already scared - do not feel the extra burden that they’re not doing enough if they don’t consider a double mastectomy".

I thought that Linda Holmes (of NPR's pop culture blog) did a really nice job of reconciling Angelina's role as both "celebrity" and "champion" in her post called "Why Angelina Jolie's Op-Ed Matters".

Legal and Policy Issues:  BRCA Genetic Testing:  On April 15, 2013, the Supreme Court heard oral arguments challenging Myriad Genetics' patents on "the breast cancer genes".  As a side note: I do not remember hearing about this story last month- perhaps because the Boston Marathon bombings also took place on April 15th?  The concern is that such patents inhibit scientific advancements, keep testing costs high- and therefore limit access to the testing.  Angelina alludes to this in her op-ed when she reveals that the BRCA1 and BRCA2 testing costs approximately $3,000 in the U.S.  Sarah Kliff from The Washington Post notes that this testing "is about to get significantly less expensive: The Affordable Care Act included the genetic test among the preventive services that insurers are required to cover without any cost sharing".

Health Communication- Risk Perception:  Nancy Shute wrote an interesting piece for NPR entitled, "Angelina Jolie and the Rise of Preventative Mastectomies".  She interviews Dr. Todd Tuttle, who raises concerns about women overestimating their risk of breast cancer (in the other breast after being diagnosed on one side) and choosing more invasive treatment like mastectomy when not medically necessary.  Shute also discusses some potential contributors to the increases in risk perception and preventative mastectomy. For example, she mentions advancements in breast surgeries/reconstructions and the "hyper-awareness" of breast cancer resulting from ubiquitous pink ribbon campaigns.  Many of these contributors were discussed two weeks ago in the must-read The New York Times Magazine article "Our Feel Good War on Breast Cancer" by Peggy Orenstein.

Reviewing the Evidence Base for Recommending BRCA Testing or Preventative Mastectomies:  Many articles focused on reviewing what we know about the effectiveness of (1) BRCA testing for predicting cancer and (2) mastectomies for preventing cancer death.  Several articles linked to the CDC feature, "When is BRCA Genetic Testing for Breast and Ovarian Cancer Appropriate"?  Sarah Kliff discusses why "Most Women Probably Shouldn't Get the Cancer Screening Angelina Jolie Did".  NPR linked to a 2010 Journal of the American Medical Association (JAMA) article that provided the "clearest evidence yet that women carrying the BRCA1 and BRCA2 genes should consider preventive surgery because they are at a very high risk for breast and ovarian cancers."

With so many articles and blogs to sift through, I could probably keep going.  But I'd like to stop and hear from you:

  • What other public health implications could result from Angelina Jolie's disclosure in today's New York Times?
  • How do you think her disclosure could impact the issues I've raised above- risk perception, policy decisions, etc?
  • I've linked to some of the articles that I read today- are there others that you would recommend to me and Pop Health readers?

Saturday, September 21, 2013

The Moore Tornado Reminds Us That "Sheltering" Is A Community-Level Concern

As the news of the Moore, Oklahoma tornado flooded in on Monday, the images were terrifying.  Over and over, Meteorologists kept saying- "it would be very hard to survive this storm above ground".  And then we heard that basements and safe rooms are not common in Moore.  Safe rooms being structures that are reinforced to withstand 200+ MPH winds.

So how can that be?  How can a town situated in an area of the country ripe with tornado activity be without basements and safe rooms?

Well- as with most public health challenges, the answers are complex:

Environmental:  The soil in the state is comprised mostly of clay.  The bedrock is mostly limestone.  Both absorb water and become unreliable foundations for a basement.

Urban Sprawl:  As The Atlantic points out, "One reason tornadoes prove so deadly now is that, given the spread of the suburbs, their funnels simply stand a better chance of touching down where people are".  Therefore, instead of striking farmland, these tornadoes are striking homes and schools and shopping centers- many without sufficient sheltering options.

Cost: Various estimates have been given over the past two days, but NBC News reports that individual home safe rooms can cost $8,000-$10,000 to construct.  There is a lottery to receive state assistance for these costs.  The most recent lottery selected 500 homeowners...out of 16,000 applications.  The city of Moore recently applied for $2 Million in federal aid to help build safe rooms in an additional 800 homes.  City officials report that the program was delayed because FEMA standards were a "constantly changing target".

There are additional cost challenges at the community-level.  NBC News reported that it would cost $1.4 Million to construct safe rooms in each school.

Access:  The City of Moore has no community (or "public") tornado shelters.  On their website, they attribute this to two reasons:  (1) People take less risk by sheltering in place and (2) There is no public building in Moore that is suitable for a shelter.

With hindsight being 20/20, it is heartbreaking  to read the following statement on their site:

"Statistically, there is only about a 1-2% chance of a tornado - of any size - striking Moore on any particular day during the spring. But of all tornadoes that do strike us (again, not very many historically), there's only a less than 1% chance of it being as strong and violent as what we experienced on May 3rd [1999]".  

Interestingly, "May 3rd" (as it is often abbreviated), shined a light on the need to shift from individual (family) shelters only to community-level ones.  Shortly after that storm, FEMA released design and construction guidance for community safe rooms.  Many communities, such as nearby Tushka, OK, have constructed such rooms very successfully.

In public health, we assess health needs and change the conversation from individual-level to community-level solutions.  We need that frame of mind to improve emergency preparedness planning for tornadoes.  As Megan Garber writes for The Atlantic:

"The old, Wizard of Oz-style model of sheltering -- every farm with its cellar -- is slowly giving way, in the age of suburban sprawl, to large shelters meant to house large groups of people".    

"Sheltering, in other words, is moving from an individual concern to a collective one". 

Tell Me What You Think:

  • What are some solutions to the challenges (environmental, cost, access) listed above?
  • What is your reaction to the shift from individual to community-level shelters?

Downtime in 2002 verses 2013

On November 13, 2002, the network core at Beth Israel Deaconess failed due to a complex series of events and the hospital lost access to all applications.   Clinicians had no email, no lab results, no PACS images, and no order entry.    All centrally stored files were unavailable.   The revenue cycle could not flow.   For 2 days, the hospital of 2002 became the hospital of 1972.  Much has been written about this incident including a CIO Magazine article and a Harvard Business School case.

On July 25, 2013, a storage virtualization appliance at BIDMC failed in a manner which gave us Hobson's choice  - do nothing and risk potential data loss; or intervene and create slowness/downtime.   Since data loss was not an option, we chose slowness.  Here's the email I sent to all staff on the morning of July 25.

"Last evening, the vendor of the storage components that support Home directories (H:) and Shared drives (S:) recommended that we run a re-indexing maintenance task in order avoid potential data corruption. They anticipated this task could be run in the middle of the night and would not impact our users.   They were mistaken.

The indexing continues to run and must run to completion to protect H: and S: drive data.  While it is running, access to H: and S: will be slow, but also selected clinical web applications such as Provider Order Entry, webOMR, Peri-operative Information System, and the ED Dashboard will be slow.  Our engineers are monitoring the clinical web applications minute to minute and making adjustments to ensure they are as functional as possible.   We are also investigating options to separate clinical web applications from the storage systems which are causing the slowness.

All available IS resources are focused on resolving this as soon as possible.  We ask that all staff and clinical services affected by the interruption utilize downtime procedures  until the issue is resolved.  We apologize for the disruption this issue has caused to patients, providers, and staff."

2002 and 2013 were very different experiences.   Here's a brief analysis:

1.  Although 2002 was an enterprise downtime of all applications, there was an expectation and understanding that failure happens.   The early 2000's were still early in the history of the web.   There was no cloud, no app-enabled smartphones, and no universal adoption of social networking. Technology was not massively redundant.  Planned downtime still occurred on nights and weekends.

In 2013, there is a sense that IT is like heat, power, and light - always there and assumed to be high performing.   Any downtime is unacceptable as emphasized by the typical emails I received from clinicians:

"My patients are still coming on time and expect the high quality care they normally receive. They also want it in a timely manner.  Telling them the computer system is down is not an acceptable answer to them.   Having an electronic health care record is vital but when we as physicians rely on it and when it is not available, it leads to gaps in care."

"Any idea how long we will be down? I am at the point where I may cancel my office for the rest of the day as I cannot provide adequate care without access to electronic records."

In 2013, we've become dependent on technology and any downtime procedures seem insufficient.

2. The burden of regulation is much different in 2013.  Meaningful Use, the Affordable Care Act, ICD10, the HIPAA Omnibus rule, and the Physician's Quality Reporting System did not exist in 2002.   There is a sense now that clinicians cannot get through each day unless every tool  and process, especially IT related, is working perfectly.

Add downtime/slowness and the camel's back is broken.

3.   Society, in general, has more anxiety and less optimism.    Competition for scarce resources  translates into less flexibility, impatience, and lack of a long-term perspective.

4.  The failure modes of technology in 2013 are more subtle and are harder to anticipate.

In 2002, networking was simple.  Servers were physical.  Storage was physical.  Today, networks are multi-layered.  Servers are virtual.  Storage is virtual. More moving parts and more complexity lead to more capabilities but when failure occurs, it takes a multi-disciplinary team to diagnose and treat it.

5.  Users are more savvy.   Here's another email:

"Although I was profoundly impacted by today's events as a PCP trying to see 21 patients, I understand how difficult it is to balance all that goes into making a decision with a vendor on hardware/software maintenance. However, I was responsible for this for a large private group on very sophisticated IT, and I would urge you to consider doing future maintenance and upgrade projects starting on Friday nights, so as to have as little impact as possible on ambulatory patient care."

My experience with last week's event will shape the way I think about future communications for any IT related issues.    Expectations are higher, tolerance is lower, and clinician stress is overwhelming.    No data was lost, no patient harm occurred, and the entire event lasted a few hours, not a few days.     However, it will take months of perfection to regain the trust of my stakeholders.

It's been 10 years since we had to use downtime procedures.   We'll continue to reduce single points of failure and remove complexity, reducing the potential for downtime.   As a clinician I know that reliability, security, and usability are critical.   As a CIO I know how hard this is to deliver every day.

Friday, September 20, 2013

The Era of Epic

In the Boston marketplace, Partners Healthcare is is replacing 30 years of self developed software with Epic.   Boston Medical Center is replacing Eclipsys (Allscripts) with Epic.   Lahey Clinic is replacing Meditech/Allscripts with Epic.  Cambridge Health Alliance and Atrius already run Epic.   Rumors abound that others are in Eastern Massachusetts are considering Epic.  Why has Epic gained such momentum over the past few years?   Watching the implementations around me, here are a few observations

1.  Epic sells software, but more importantly it has perfected a methodology to gain clinician buy in to adopt a single configuration of a single product.   Although there are a few clinician CIOs, most IT senior management teams have difficulty motivating clinicians to standardize work.  Epic's project methodology establishes the governance, the processes, and the staffing to accomplish what many administrations cannot do on their own.

2.  Epic eases the burden of demand management.   Every day, clinicians ask me for innovations because they know our self-built, cloud hosted, mobile friendly core clinical systems are limited only by our imagination.   Further, they know that we integrate department specific niche applications very well, so best of breed or best of suite is still a possibility. Demand for automation is infinite but supply is always limited.   My governance committees balance requests with scope, time, and resources.   It takes a great deal of effort and political capital.   With Epic, demand is more easily managed by noting that desired features and functions depend on Epic's release schedule.   It's not under IT control.

3.  It's a safe bet for Meaningful Use Stage 2.   Epic has a strong track record of providing products and the change management required to help hospital and professionals achieve meaningful use.  There's no meaningful use certification or meaningful use related product functionality risk.

4.  No one got fired by buying Epic.   At the moment, buying Epic is the popular thing to do.   Just as the axiom of purchasing agents made IBM a safe selection,   the brand awareness of Epic has made it a safe choice for hospital senior management.   It does rely on 1990's era client server technology delivered via terminal services that require significant staffing to support, but purchasers overlook this fact because Epic is seen in some markets as a competitive advantage to attract and retain doctors.

5.  Most significantly, the industry pendulum has swung from best of breed/deep clinical functionality to the need for integration.   Certainly Epic has many features and overall is a good product.   It has few competitors, although Meditech and Cerner may provide a lower total cost of ownership which can be a deciding factor for some customers.   There are niche products that provide superior features for a department or specific workflow.   However,  many hospital senior managers see that Accountable Care/global capitated risk depends upon maintaining continuous wellness not  treating episodic illness, so a fully integrated record for all aspects of a patient care at all sites seems desirable.  In my experience, hospitals are now willing to give up functionality so that they can achieve the integration they believe is needed for care management and population health.

Beth Israel Deaconess builds and buys systems. I continue to believe that clinicians building core components of EHRs for clinicians using a cloud-hosted, thin client, mobile friendly, highly interoperable approach offers lower cost, faster innovation, and strategic advantage to BIDMC.  We may be the last shop in healthcare building our own software and it's one of those unique aspects of our culture that makes BIDMC so appealing.

The next few years will be interesting to watch.   Will a competitor to Epic emerge with agile, cloud hosted, thin client features such as Athenahealth?   Will Epic's total cost of ownership become an issue for struggling hospitals?   Will the fact that Epic uses Visual Basic and has been slow to adopt mobile and web-based approaches provide to be a liability?

Or alternatively, will BIDMC and Children's hospital be the last academic medical centers in Eastern Massachusetts that have not replaced their entire application suite with Epic?   There's a famous scene at the end of the classic film Invasion of the Body Snatchers, which depicts the last holdout from the alien invasion becoming a pod person himself.  At times, in the era of Epic, I feel that screams to join the Epic bandwagon are directed at me.

Building Unity Farm - The Barn Swallows of Unity Farm

One of the side effects of creating the orchard at Unity farm was opening about 2 acres of airspace adjacent to our pasture.  This has attracted  many new species of birds which now dance and dive in the clearing between our woodland and marsh.   Since adding the orchard we've seen a significant increase in our barn swallow population.  Throughout the day, at least 5 adults dash at high speed around their own open air playground, eating mosquitos and enjoying their social community of birds.

Our barn has two sliding doors which open to the male and female paddocks.  The swallows retreat to the barn for shelter at night and during the rain.   Recently a mating pair built a nest on top of a porcelain light socket.   We use LED lightbulbs in the barn, so the socket does not get hot.   The nest is a delicate combination of mud, sticks, great pyrenees fur, and feathers from our chickens/guinea fowl, pictured above.

This week, 4 swallow babies are fledging.  Two are pictured below balanced on a barn door rail.   Watching the parents feed them for the past several weeks, I've read a great deal about swallows and can now answer some lifelong questions I've had since 1975, when King Arthur first had a dialog about swallows with the guardian of the bridge.

1.  Are the swallows of Unity Farm considered European or African?

European swallows are migratory and are widespread throughout the Northern Hemisphere.   African swallows are non-migratory and are typically found in in Botswana, Republic of the Congo, Democratic Republic of the Congo, Gabon, Lesotho, Malawi, Namibia, South Africa, Zambia, and Zimbabwe.    Thus, if asked, you can definitively answer that the barn swallows of Unity Farm are European.

2.  Much of the day the adult swallows gather insects to feed to their young.  I've watched them busily carrying food and nesting materials as the cruise through the paddocks and into the barn.     When they're done feeding their babies and reinforcing the nest, they fly above the paddock turning and twisting at high speed before deftly returning to the barn.   Watching them makes me wonder - just how fast do they fly when unencumbered i.e. What is the airspeed velocity of an unladen swallow (European)?

Luckily much research has been done on this topic.

A 54-year survey of 26,285 European Swallows captured and released by the Avian Demography Unit of the University of Capetown finds that the average adult European swallow has a wing length of 12.2 cm and a body mass of 20.3 grams.

European Swallow flies at cruising speed with a frequency of roughly 15 beats per second, and an amplitude of roughly 22 cm.   However, some other researchers have measured a lower frequency of 7-9 beats per second among some swallows.

Because wing beat frequency and wing amplitude both scale with body mass and flight kinematic data is available,  we can  estimate airspeed (U).

Graham K. Taylor et al. show that as a rule of thumb, the speed of a flying animal is roughly 3 times frequency times amplitude (U ≈ 3fA).

Based on wing beats per minute, body mass, and amplitude, the answer for our swallows appears to be 24 miles per hour (11 meters per second).   So if on your quest to visit Unity farm, you are asked the airspeed velocity of an unladen swallow (European), you know the answer!

The July HIT Standards Committee

The July HIT Standards Committee included a robust discussion of Benefits and Formulary standards, a brief overview of our work on image exchange thus far, preparations for the July 23 HITSC Implementation Workgroup and HITPC Meaningful Use and Certification and Adoption Workgroup joint hearing on Implementation and Usability, an overview of ONC S&I Framework activities, and a discussion of the CMS electronic submission of medical documentation planning.

We started the meeting with a presentation from Kim Nolen and John Klimek reviewing the final recommendations for enhanced formulary and benefit standards.   While short term incremental improvements are important, the committee was more focused on the Stage 3 trajectory for formulary and benefits transactions.   Ultimately, the committee made 5 recommendations

1. We endorse the adoption of RxNorm as the preferred medication substance vocabulary in formulary and benefits transactions
2. We support standardizing content on NCPDP Formulary and Benefits version 3.0 to simplify current batch formulary import implementations in the short term but prefer the certification criteria for stage 3 focus on the real time transactions described in recommendation #5
3. We recommend that batch formulary transport standards move from FTP to Direct/XDR to align better with existing Meaningful Use transport standards
4. We recommend that patient matching to pharmacy benefits utilize PCN/BIN/Group Number to more accurately reflect the benefits of the patient's plan.
5. ONC should facilitate development of national standards for real time lookup of patient specific drug/dose benefits by prescribers at the point of care including estimated patient out of pocket cost at the time of the prescription order.

Also, I provided this image exchange update.  We will continue our hearings with more expert testimony this Friday.

Next we heard from Liz Johnson and Cris Ross about their planned July 23 implementation and usability hearing.   Their group has prepared great questions for its four panels - Eligible Professionals, Eligible Hospitals, Health Information Exchange/Interoperability, and Usability

Doug Fridsma provided a comprehensive update about the S&I framework activities, identifying all the current and planned deliverables for the many groups working on these important future looking projects.   Especially interesting was the data accress framework project which incorporates many of the previous point solution projects like QueryHealth and targeted query ("pull" of medical records from multiple sources).

Jodi Daniel offered this ONC Policy and Program Update focusing on the Health IT Patient Safety Action & 
Surveillance Plan.

Finally Melanie Combs-Dyer from CMS and Bob Dieterle presented the roadmap for fully electronic closed loop CMS medical documentation submission to support medical review by Medicare Administrative Contractors (MACs), Medical Review (MR) Departments,
Comprehensive Error Rate Testing Contractor (CERT), Payment Error Rate Measurement Contractor (PERM), and Medicare Recovery Auditors (formerly called RACs).   The digital signature provisions which provide provenance and integrity protections generated the most discussions and these will be reviewed by the HITSC Privacy and Security Workgroup and Clinical Operations Workgroup.

In my introductory remarks to the meeting, I stressed the importance of focusing our standards work on those items which will support the hard work of hospitals and professionals to achieve all phases of meaningful use, ICD-10, Accountable Care, and compliance/regulatory mandates.   Formulary support, image sharing, "pull" based health information exchange,  ensuring are EHRs are safe, and supporting Medicare review workflows definite fall into that category.

As the meeting closed, we thanked MacKenzie Robertson for her work as our FACA facilitator.   She will be replaced by Michelle Consolazio.

Image Exchange

Last week, the Clinical Operations Workgroup of the HIT Standards Committee held its third hearing on image exchange, seeking testimony from Hamid Tabatabaie, CEO of LifeImage and Michael Baglio, CTO of LifeImage.

He made several important points
1.  We should think of image exchange as having two major categories - local and long distance.    DICOM works well for modality to PACS connectivity within an enterprise (local).   DICOM was never designed for internet-based cross organizational image sharing.   DICOM images tend to be large, including a vast amount of metadata with every image object in a study.    DICOM was also never designed to work well with the kind of firewalls, load balancers, and network security appliances we have today.

2.  Two image exchange architectures have been used in the marketplace to date, which Hamid called "iTunes" and "Napster",  classifications first suggested by Dr. Keith Dreyer.

iTunes refers to the centralization of images into a single repository or what a appears to be single repository - it may actually be a clearinghouse to other image stores, but the user never knows that.   Query/response transactions against this central repository can be straightforward, using standards such as Blue Button Plus/Direct for share, access, download.

Napster refers to a decentralized, federated model in which images are not placed in a single repository -    an index of images and their location is all that is centralized.   Typically, query/response is done with standards such as XDS-i.   XDS itself was never designed for image exchange and is incomplete.  It can be challenging to search for a single exam on a known date of a known modality type.

3. Current standards do not include any privacy metadata and security is not built in.  Future standards should enable applications to restrict image flows based on consent/patient preferences.

4.  We need a web friendly method for visualization that does not require the download of a proprietary viewer, one that is often operating system specific.   Consumers should be able to view thumbnails of images on a smartphone, tablet, or the device of their choosing without special software.   If the full DICOM object is needed (patient mediated provider to provider image exchange), download and transmission should be enabled using standards such as REST, OAUTH2/OpenID, and secure email.

5.  Hamid made a forward looking statement that should be carefully considered as we plan the lifecycle of existing Radiology Information Systems (RIS) and Picture Archiving and Communication Systems (PACS) systems.   He is seeing EHR features expand to cover many aspects of RIS workflow.   If scheduling, image viewing, report construction with templates/front end voice recognition, and easy exchange of reports with clinicians are supported by the EHR, maybe radiologists (some of which want to qualify for meaningful use payments) will start using increasingly capable EHRs instead of RIS.   Vendor neutral archives (VNA) which store images of all "-ologies"  and enable easy search and retrieval may replace PACS.   Imagine 5 to 10 years from now when RIS/PACS no longer exists and is replaced by EHR, HIE,  and VNA.   Interesting possibility.

Great testimony.    In the past when I've suggested DICOM is not ideal for internet-based multi-organizational exchange, I've been criticized.   In the past when I've suggested that DICOM has issues of vendor-specific proprietary metadata extensions, cumbersome viewers, and heavy payloads, I've been challenged.   It's refreshing to hear from someone doing the hard work of high volume image sharing that current standards not ideal.  We need new approaches to move payloads efficiently on the internet, view images via web-browsers, facilitate easy searching, support security, and enable multiple provider/patient/group sharing use cases.